Bull Neck Research Articles

Clinical spectrum and outcomes of the 2019-2020 pediatric diphtheria outbreak in Yemen

Background Diphtheria is an acute bacterial infectious disease characterized by serious morbidity and mortality. Outbreaks continue to occur in developing countries despite national vaccination programs. Vaccination, early recognition the disease, and adequate intervention are needed to avoid devastating outcomes.
 Objective To describe the clinical spectrum of childhood diphtheria and its association to outcomes during the 2019-2020 diphtheria outberak in Yemen.
 Methods This was a retrospective study to assess the demographic, clinical features, and outcomes of paediatric respiratory diphtheria in patients with diphtheria during the outbreak from September 2019 until May 2020 admitted at Mukalla Maternity and Children Hospital. We used SPSS 22 version for data analysis.
 Results There were 34 culture-confirmed diphtheria cases included in this study, their age ranged from 13 months to 15 years old. Most of the cases (76.5%) happened to children at more than 5 years old. There was no gender difference. Of these 34-positive diphtheria, 79.4% from Hadramout and 17.6% from Shabwa governorate. Most of the cases (35.3%) were admitted in December. More than half of the patients (52.9%) were unimmunized. Fever, sore throat, and enlarged tonsils were presented in all patients, dysphagia (82.4 %), pseudomembrane (91.7%), bull neck (52.9%), and stridor (8.8%) were also found in some patients. Complications included acute renal failure (20.6%), disseminated intravascular coagulation (DIC), shock (17.6%), and myocarditis (8.8%). Significant poor outcome (P< 0.05) was associated with bull neck, myocarditis, acute renal failure, DIC, and shock. The case fatality rate (CFR) was 20.6%.
 Conclusion Fever, sore throat, tonsillitis, pseudomembrane, and bull neck are high index suspicion of diphtheria and anticipation of ominous outcome. The shifting of occurrence of diphtheria to older age group indicates the need for booster(s) diphtheria toxoid vaccine in addition to improving and strengthening the current immunization program.

A RETROSPECTIVE STUDY OF DIPHTHERIA AND ITS COMPLICATIONS IN A TERTIARY CARE HOSPITAL,GGH, GUNTUR

AIM AND OBJECTIVE: To study clinical presentation and complication in diphtheria in pediatric agegroup. Retrospectively 25 clinical diphtheria cases who got admitted to the MATERIALS AND METHODS: isolation unit of Government General hospital from August 2021 to July 2022 were taken for this study. The epidemiological details, vaccination status, clinical prole, treatment given, and interventions done with outcome were studied. The RESULTS: common symptoms observed were throat pain seen in 20 cases (80%), fever seen in 18 cases (72%), dysphagia seen in 10 cases (40%), bull neck seen in 6 cases (24%), palpitations seen in 04 cases (16%), Nasal regurgitation in 02 (8%).Of the 25 patients, 5 (20%) patients had completed vaccination, 20 (80%) cases were either unimmunized or partially immunized as per their age. The complications observed were cardiac involvement evident through elevated serum transaminase and ECG changes seen in 06 cases (24%), neurological involvement seen in 04 cases (16%), renal failure seen in 02 cases (8%), Airway compromise 02 cases (8%). A total number of 8(32%) patients died with complications. Diphther CONCLUSION: ia incidence is relatively more in the age-group >5 years. The common symptoms are throat pain followed by fever, dysphagia, and bull neck. Common complications observed are myocarditis associated with high mortality, palatal palsy, renal failure, and Airway compromise. An increase in vaccination coverage is an effective preventive measure to reduce the incidence of diphtheria.

Clinico-epidemiological Profile of Children with Diphtheria in Tertiary Care Hospital of Nepal

Introduction: This study was conducted with the aim to describe the clinical presentation of diphtheria in children, relationship between clinical disease and immunization status, complications of the disease and adverse events due to anti diphtheria serum (ADS). Methods: All patients admitted at Tribhuvan University Teaching Hospital, Kathmandu from July 2016 to November 2018 with clinical diagnosis of diphtheria were included in this study. Results: There were total 12 children and age ranged from five to 15 years, out of which seven (58%) were males and five (42%) were females. All of them were immunized except one whose immunization status was unknown. All of them had tonsillopharyngeal diphtheria. Four patients (33%) also had nasal and five (42%) patients had additional laryngotracheal diphtheria. Seven patients had bull neck on presentation. Four patients had airway obstruction due to laryngotracheal diphtheria requiring tracheostomy. Throat swab for Corynebacterium Diphtheria by Albert stain and Gram stain were positive in 10 patients, and in nine, diagnosis was confirmed by culture. Six patients (50%) were given anti diphtheria serum (ADS) out of which four patients (66.66%) developed anaphylaxis. Myocarditis was the commonest complication seen in four patients (25%). All children with myocarditis developed complete heart block (CHB) and none of them survived. Conclusions: Tonsillopharyngeal diphtheria was the most common clinical presentation and myocarditis was highly fatal complication. This study emphasizes on the need for careful surveillance, early laboratory confirmation and careful administration of ADS in patients with clinical diagnosis of diphtheria.

Diphtheria Outbreak During Covid-19 Pandemic in Katsina, North-Western Nigeria

Context: The impact of coronavirus disease 2019 (COVID-19) pandemic on vaccine-preventable diseases, including diphtheria, may hamper the previous gains made in the eradication of the disease. Aims: We report the epidemiological profile, clinical features, laboratory findings, and hospitalization outcomes amongst cases of diphtheria managed at Federal Medical Centre, Katsina, Nigeria during the first wave of COVID-19 pandemic. Settings and Design: This was a retrospective review of cases of diphtheria managed between July and December 2020. Methods and Material: We extracted the clinical (socio-demographics, clinical features, and hospitalization outcomes) and laboratory findings (full blood counts, electrolytes, urea and creatinine) from the record of the children. Statistical Analysis Used: Using SPSS, we carried out a descriptive analysis and applied binary logistic regression to determine factors associated with death. Level of statistical significance was set at P < 0.05. Results: A total of 35 cases of diphtheria were admitted and managed from 1 July to 31 December 2020. The mean age of the children was 7.6 ± 3.1 years. Males were 15 (42.9%). There were 24 deaths (case fatality of 68.6%). Clinical findings were comparable between survivors and non-survivors except the bull neck, which was more common among non-survivors (P = 0.022). The median duration of hospitalization was shorter in those that died (P = 0.001). The age, sex, immunization status, leukocytosis, and biochemical features of renal impairments were not predictive of deaths. Prescence of bull neck was predictive of death (adjusted odds ratio 2.115, 95% CI 1.270, 3.521). Conclusions: The study shows a high number of cases of diphtheria over a short period of six months with high mortality. Amongst the clinical and laboratory variables, only presence of bull neck was predictive of death.

Microbiological and Clinical Aspects of Diphtheria-Confirmed Cases from Capital City of Indonesia, Jakarta, and Surrounding Areas in 2017

Background: The World Health Organization reported Indonesia as one of the countries with the most prevalent cases of diphtheria worldwide. The microbiological aspects of diphtheria-inducing bacteria are of great significance in tracing disease transmission and case management. However, clinical aspects are critical for updating clinical features and case management in the field, which may sometimes differ from theoretical foundations. Objectives: This study aimed to identify the microbiological and clinical aspects, including molecular typing and case fatality rates, in diphtheria-confirmed cases from the capital city of Indonesia, Jakarta, and surrounding areas in 2017. Methods: The microbiological aspect of 40 diphtheria-confirmed cases were obtained by re-identify diphtheria-inducing bacteria isolated from the samples, while the clinical aspects of the cases were obtained from the medical records and epidemiological data. The chi-square test was used to examine the correlation between fatal cases and myocarditis and diphtheria antitoxin administration delay. In this study, P ≤ 0.05 was set as the significance level. Results: All 40 diphtheria confirmed cases were induced by toxigenic Corynebacterium diphtheriae with two biotypes, namely intermedius (60.0%) and mitis (40.0%). There are six sequence types of bacteria with two main sequence types, ie, ST534 (46.4%) and ST377 (35.7%). The proportions of cases that had a fever and sore throat were 72.5% and 77.5%, respectively; however, the prevalence rates of the cases with pseudomembrane and bull neck were 100% and 47%, respectively. Most cases were administered a combination of penicillin or erythromycin with other antibiotics (40%), and 22.5% of the cases only received penicillin. Myocarditis was noticed in three fatal cases, and their relationship was statistically significant (P = 0.000). All five fatal cases (12.5% of cases) received diphtheria antitoxin (DAT) lately or had not received it yet. Conclusions: Toxigenic C. diphtheriae with two biotypes (namely mitis and intermedius) and two main sequence types (ie, ST534 and ST377) was the causative agent of diphtheria-confirmed cases from Jakarta and surrounding areas in 2017. It was also concluded that those fatal cases were correlated with myocarditis complications.

Diphtheria outbreak in Jakarta and Tangerang, Indonesia: Epidemiological and clinical predictor factors for death

BackgroundIn 2017, a diphtheria outbreak occurred in several provinces in Indonesia. The aim of this study was to identify predictors of mortality outcome of pediatric patients with clinical diphtheria.MethodsA retrospective cohort study was conducted using patient medical records at five referral hospitals in the Province of Jakarta and one in Tangerang District, Banten Province during January 2017 to 31 August 2018. All children in the age group of 1–18 years old discharged with diagnosis of clinical diphtheria formed the study group. All anonymized patient data were evaluated for demographic issues, clinical features, immunization status, complication, laboratory profiles and outcome.ResultsA total of 283 patients with clinical diphtheria were included in the study group with case fatality rate of 3.5%. All mortal patients had the complication of myocarditis. Regression analyses revealed factors for predicting mortality. Incomplete primary diphtheria toxoid immunization, stridor, bull neck, leukocytosis ≥15 x109 cells/L and thrombocytopenia ≤150 x109 cells/L in each combination for 2 predictors modeling were correlated with death.ConclusionsWe report key predictors of mortality in pediatric patients with clinical diphtheria. The presence of these features when admitted to the hospital must be taken into account, because they can lead to fatal outcome.

Prospective study of patients with membranous patch over the tonsil at GIMS, Kalaburagi

<p><strong>Background:</strong> Current study was done to know various clinical aspects of membranous patch over the tonsil.</p><p><strong>Methods: </strong>Data for the study were collected from patients who presented with membranous patch over the tonsil in the department of ENT at GIMS, Kalaburagi from January 2019 to December 2019. This is a prospective case study. 225 patients were included in the study. Once patient was presented to us detailed history, examination and necessary investigations were done.</p><p><strong>Results:</strong> The present study included 225 patients out of which out of which females were 132 (59%) and males were 93 (41%). The predominant clinical features were sore throat (225 cases), fever (212 cases), dysphagia (90 cases) and bull neck (45 cases). The most common cause of membranous patch over tonsil was found to be diphtheria (68%) followed by streptococcal tonsillitis (30%) and others (2%). In our study microbiological investigations like Albert stain was positive in 153 cases and culture was positive in 140 cases.</p><p><strong>Conclusions: </strong>It was observed in our study that diphtheria constitutes the majority (68%) and the incidence of adult is almost on par with paediatric age group. Despite of UIP we have seen increased incidence in the adult age group. Hence it requires the health agencies and the Government to increase immunization coverage, as India has witnessed the highest number of cases in the world for the year 2015. As evident from the shift in age groups being infected, adult booster dose has to be introduced at 10 years interval.</p>

Diphtheria: a re-emerging public health challenge

<p class="abstract">Diphtheria is a highly contagious, potentially life threatening bacterial infection caused by <em>Corynebacterium diphteriae. </em>Diphtheria is transmitted from person to person, usually through respiratory droplets and can lead to severe breathing problems, heart failure, blood disorders and death. Diphtheria was basically eliminated after the introduction of the vaccine in the 1940-1950s. However there is presently global concern that diphtheria is reemerging. We herein report nine cases of diphtheria presenting within a period of six months. All cases presented with sore throat, fever, membrane in the oropharynx and bull neck. Eight of the cases had never been immunized against diphtheria. All cases progressed and developed various complications with 8 of the cases dying. None of the cases had diphtheria antitoxin. This cases present the potential for this highly fatal but preventable disease reemerging and the need to be aware of epidemiological features, clinical signs and symptoms of diphtheria so that cases can be promptly diagnosed and treated, and further public health measures can be taken to contain this serious disease.</p>

Clinical spectrum and outcomes of pediatric diphtheria

Background Although vaccination programs have succeeded in reducing the incidence of diphtheria, it remains a health problem in Asia, including Indonesia.
 Objective To investigate the clinical spectrum and outcomes of pediatric diphtheria in Wahidin Sudirohusodo Hospital.
 Methods This study was a retrospective review of childhood diphtheria medical records from January 2011 to December 2017 in Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi. Recorded data consisted of age, gender, nutritional and immunization statuses, signs and symptoms, throat swab culture results, complications, and outcomes. 
 Results Of 28 subjects aged 9 months to 17.10 years, the majority were >5 years (57.1%) and male (60.7%). Subjects’ mean age was 6.15 years and 82.1% of cases were well nourished. Overall, 85.7% had received complete immunizations, while 14.3% were not immunized, having received neither basic nor booster vaccines. The presenting manifestations were fever, pseudomembranes, and sore throat in all subjects, enlarged tonsils (78.57%), dysphagia (67.86%), cough (57.14%), headache (57.14%), hoarseness (67.86%), bull neck (25%), and myocarditis (14.3%). Most subjects had hospital stays of >10 days (67.9%). Mortality was 14.3%, usually in those admitted with a late, deteriorating condition and dying before getting optimal treatment. Poor outcome was significantly associated with the lack of basic or booster immunizations, poor nourishment, bull neck, myocarditis, and hospital stays < 5 days (P<0.05 for all). 
 Conclusion The clinical spectrum and outcomes of pediatric diphtheria in this study are relatively similar to reports from other hospitals. Mortality was mostly in patients who lack basic or booster immunizations, are poorly nourished, or have bull neck, myocarditis, or hospital stays < 5 days.

Clinico-epidemiological profile and predictors of outcome in children with diphtheria: a study from northern India.

Diphtheria, a vaccine preventable disease in children, is still being reported from India. Details of 99 children with a clinical diagnosis of diphtheria admitted to a paediatric tertiary care teaching and referral hospital between January 2008 and December 2015 were collected retrospectively and analysed. The median (interquartile range [IQR]) age of the study group was 7.0 years (IQR = 5.0-8.0 years). Nearly two-thirds were unimmunised. Clinical features included fever (97%), dysphagia (82%), sore throat (67%), bull neck (54%), stridor (40%), neuropathy (27%) and nasal discharge (14%). Throat swab for Albert stain was positive in only 21% of cases and C. diphtheriae was isolated in only 28%. Complications included airway compromise (61.7%) followed by myocarditis (35.4%), acute kidney injury (22.3%), thrombocytopenia (25.3%) and neuropathy (27.3%). In all, 66% survived, 23% died and 11% opted for discontinuity of care owing to unfavourable prognoses. On multivariable logistic regression analysis, shorter duration of symptoms before presentation to our hospital was an independent predictor of unfavourable outcome (adjusted odds ratio = 0.88, 95% confidence interval = 0.79-0.99, P = 0.03).

Clinical profile and predictors of outcome of patients with diphtheria in tertiary care pediatric centre from Southern India

Background: Diphtheria is still a fatal infectious disease even in this era of universal immunization. The disease has been completely eradicated in most of the developed countries. On the contrary, in developing countries, although the incidence has drastically declined, still account for 80-90% of global burden. The objectives of this study is to study the clinical profile and predictors of outcome of patients with diphtheria.Methods: All children between the age group of 0 to 15 years admitted with signs and symptoms of diphtheria during January to August 2017 formed the study group. Throat swab for Albert’s stain and culture sensitivity were sent in all patients at the time of admission. All children were started on parenteral crystalline penicillin and Anti Diphtheritic Serum as recommended. All details that is demographic data, clinical features, immunization status, complications and outcome were entered in a proforma and analysed. Several variables were compared among the survivors and non-survivors to determine the predictors of outcome. Outcome is defined as either recovered or died.Results: A total of 42 patients were included in the study group. Among 42 patients, 21 (50 %) were between 5-10 years, 12 (28 %) were between 0-5 years and 9 patients (22 %) were more than 10 years. Most common symptoms were fever followed by throat pain, difficulty in swallowing and bull neck. Alberts stain was positive in 83% of cases and culture positivity in 30% of cases. Myocarditis (47%) was the most common complication followed by acute kidney injury (40%), airway compromise (59%) and thrombocytopenia (42%). A total number of 19 patients died.Conclusions: Diphtheria is highly fatal disease with increased mortality. Myocarditis was the commonest and most serious complication. Presence of myocarditis, AKI, thrombocytopenia, airway compromise and inadequate immunization are important predictors of outcome.

Clinical profile and outcome of diphtheria in central India: a retrospective observational study

Background: Although, diphtheria is eliminated by many developed countries by effective immunization, still diphtheria continues to be endemic in India and leading cause of morbidity and mortality, especially in areas in the border of the two states. The objective of the present study was to recognize the clinical profile, morbidity and mortality pattern of diphtheria and to study their immunization status as a retrospective observational study performed in pediatric wards and paediatric intensive care unit.Methods: The medical records were recovered from the case files, searching for cases diagnosed as diphtheria from the Medical Record Section and Statistical Service of the institute. A pre-established protocol was formed after approval from institutional ethical committee. Case study included suspected, probable and confirmed cases of diphtheria as per the WHO definition guidelines. All the relevant data and information regarding age, gender, residence, socioeconomic status, immunization status, clinical details, laboratory investigation, complications, and treatment provided, and outcome were recorded.Results: Amongst 47 patients, 55.32% were >5years and mean age was 6.46±3.08 years with no difference in sex distribution. 2(4.25%) patients were completely immunized, 27(57.45%) were partially immunized and 18(38.30%) were not immunized. An immunization rate was less in females as compared to males. All patients presented with fever and membrane in throat followed by throat pain 95.74%, enlarged/congested tonsils 80.85%, respiratory difficulty 68.08%, dysphagia 59.57% bull neck 48.94% and voice change 36.17%. Myocarditis was the commonest (42.55%) complication followed by palatal palsy (14.89%), polyneuropathy (8.51%), acute renal failure (4.25%) and DIC & shock (4.25%) were observed. Case fatality rate was 21.28%. Maximum numbers of cases were noted during the rainy season.Conclusions: Shifting of occurrence of diphtheria in the age group of 5-15 years suggest the need to improve and strengthen the immunization activity specially booster doses in the border districts as most of the cases were from areas at the border of two states.

Diphtheria Outbreak in Bait Hulboob, Wasman Villages, Ibb governorate - Yemen, September 2017

Background: Remerging of diphtheria outbreaks have been associated with wars and threaten the health of children and adult. On 25th of September 2017 surveillance officer of Ibb governorate received a notification from surveillance coordinator of Alsaddah district about suspected deaths due to diphtheria. A team from Ibb surveillance office was sent to investigate on 26/09/2017. Objective: To verify the existence of an outbreak, describe its epidemiology and recommend preventive and control measures. Methods: A descriptive study was done. WHO case definition was used. A line list was created, active case finding, and clinical diagnosis were performed. Records of surveillance and vaccinations programs were reviewed. Data was entered and analyzed using Excel program. Descriptive statistics were performed. Results: A total of 63 cases were identified. The first case was in Epi week 34, the highest peak with 32 cases were in week 38. The index case was 17 years old male from Bait Hulboob village. The majority of cases 47 (74%), were from that village. Almost three quarters of cases 45 (71%) were males, 22 cases (35%) among children aged from 5-10years. 43 cases (68%) was unvaccinated and the rest was partially vaccinated. All presented with pseudo membrane, 42 cases (67%) with sore throat and 10 (16%) with bull neck. The attack rate was 15/1000. 4 cases died (the case fatality rate was 6%). Conclusions: Diphtheria outbreak was clinically confirmed. Low vaccination coverage. Vaccination campaign for population and provision of Diphtheria antitoxin for patients are urgently recommended. Immunization and health education should be emphasized by governorate authority.

Aquoeous Extract of Neem Leaves (Azadirachta Indica) Decrease Expression of Immunoglbulin E (IgE) and Interleukin 4 (IL-4) in Gingiva Tissue of BALB/c Mice Injected by Ovalbumine

Allergy has been such a difficult disease to cure. Some anti-allergic drugs on the market caused side effects such as dryness of mucous membranes, confusion, dizziness, dry mouth, constipation, difficulty urinating and blurred vision, bull neck and moon face. It is difficult to find anti-allergic drugs with minimum side effects. Aim. The research aimed to find alternative anti-alergic agent, it was aquoeous extract of Neem leaves. In particular, this study analysed modulation of aquoeous extract of Neem leaves to expression of Ig E and IL-4 in gingival tissue. Materials and Methods. A total 15 BALB/c Mice was divided into three groups, i.e controle group (no treatment were introduced), Ova group (On days 0, 7, 14 submucous injected with ovalbumine), Neem group (were given with aquoeous extract of Neem leaves 200 mg/day/kg body wieght and injected with ova). Ova injection was 25 μL (in 2 mg/mL PBS), while neem leaves extract were given by oral sondation. IgE and IL-4 were analysed in gingival tissue on day 21 by imunohistochemistry method. Parameters are amouts of leucocytes that expressed IgE and IL-4. Results. ANOVA and LSD test showed that aquoeous extract of Neem leaves could decrease IgE and IL-4 expression significantly (p<0,05) in gingival tissue. Conclusion. Aquoeous extract of Neem leaves could be used as an alternative for anti-alergic agent. Key words : Aquoeous Extract from Neem Leaves ; Azadirachta Indica ; Ig E ; IL-4 ; ovalbumine ; oral

Diphtheria: It is still prevalent!!!

BackgroundDiphtheria is a respiratory infectious disease of childhood. It is a fatal disease and may cause complications if not recognized early and treated properly. Despite availability of effective vaccination it continues to be reported from many parts of the world particularly developing countries. ObjectiveTo assess the demographic and clinical characteristics of diphtheria patients, and the predictors of outcomes of respiratory diphtheria. MethodsA prospective analysis of 180 patients with a clinical diagnosis of respiratory diphtheria admitted from 2011 to 2014 at a tertiary referral hospital. They were evaluated with respect to demographic details, immunization status, clinical features, complications and outcomes. ResultsMost common age group affected was children less than 5 years of age (87 cases, 48.33%). The peak incidence of diphtheria was seen in the months of September and October (111 cases, 62%). Majority of the patients were unimmunized (54%), followed by partially immunized (21%). The most common complication was respiratory in 80 cases (44%), followed by cardiac complications in 54 cases (30%), and renal (16%) and neurological complications (10%). Cardiac complications were associated with the highest mortality rate (63%). The presence of bull neck and pseudomembrane score >2 was associated with a high mortality. ConclusionDiphtheria is still a preventable public health problem in many developing countries. Improved vaccination coverage, including booster dosage, coupled with early detection and effective treatment, may all reduce incidence and mortality.

An interesting case of diphtheritic neuropathy

Diphtheritic neuropathy seldom has been observed nowadays in India beyond 1980 probably due to effective im- munization. We report an 11-year-old adolescent girl, not adequately immunized who had pharyngitis with bull neck and sub- sequently presented with palatal weakness, accommodation paralysis, lower cranial nerve palsy and peripheral neuropathy, features characteristic of diphtheritic neuropathy. She was managed with supportive treatment. The specific treatment (diphtheria antitoxin) was not useful in our child as the child presented 4 wk after diphtheria infection. This case report will increase the awareness of sporadic occurrence of a rare disease among fellow pediatricians.

Historical assessment of diphtheritic myocarditis from a hospital in northeastern Thailand

Abstract Background: Although there have been many descriptive studies of diphtheria from resource limited countries, descriptions of the natural history of diphtheritic myocarditis in patients from these countries are scarce. Objective: To present the natural history of diphtheritic myocarditis from a hospital in northeastern Thailand. Methods: The clinical features of 38 patients with diphtheria admitted to the Khon Kaen University Hospital in northeastern Thailand between 1983 and 1996 were reviewed. Results: Of the 38 cases of diphtheria, 10 progressed to diphtheritic myocarditis (26%). Electrocardiographic findings of the 10 patients with myocarditis were myocardial and conduction abnormalities. The presence of a clinically severe (toxic) type (P < 0.001) or a swollen neck (bull neck) (P = 0.001) was a predictor of the occurrence of myocarditis. Five (50%) of the 10 patients with myocarditis had conduction abnormalities (third-degree atrioventricular block 3, left bundle branch block 1, and right bundle branch block 1). Four patients with severe symptomatic bradyarrhythmia (third-degree atrioventricular block 3, and left bundle branch block 1) received ventricular pacing, and 3 patients died after this pacing. Echocardiographic abnormalities of left ventricular dilatation and myocardial hypertrophy were found in all 5 patients with conduction abnormalities. All 6 of 7 survivors of diphtheritic myocarditis had normal 12-lead electrocardiographic results at 1-month follow-up. A patient who was the survivor of third-degree AV block had an electrocardiographic finding of flat T waves, and with a complete echocardiographic normalization of left ventricular dilatation and myocardial hypertrophy. Conclusion: The present study confirms that increasing diphtheria immunization coverage in the population remains the most important strategy for the control of diphtheria. In resource limited countries, clinical findings, electrocardiography, and sometimes where available, echocardiography are helpful in assessing the severity of diphtheritic myocarditis, decision making of acute management, and predicting fatal outcome.

Resurgence of Diphtheria: Are We ready to treat?

ABSTRACT Objectives To create awareness amongst the medical faculty about a forgotten fatal disease (diphtheria). To determine the age distribution, immunization status, presenting features, prognosis with respect to duration after which they took medication and effect of ADS on recovery in cases of faucial and laryngeal diphtheria. To stress on the importance of DTP immunization to control diphtheria. Study method In this study, 15 patients who presented to the Government general hospital between July and September 2013 with membranous tonsillitis were enrolled. In every diphtheriaproven case, we administrated antidiphtheric serum (ADS) as early as possible along with injection crystalline penicillin (CP) and oral erythromycin. Tracheostomy was done in two cases who presented with stridor. Patient variables and their correlation with recovery were studied. Results Out of 15 cases of membranous tonsillitis, nine tested positive for diphtheria; eight, smear positive and one, culture positive. Of these nine cases, eight were between 9 and 13 years old and one was a 50-year-old man. While tracing immunization status, it was found that three children (33%) were not immunized, four children (22%) had not taken booster doses, and in one child and the adult, immunization history was unknown. Clinical presentation of two of the unimmunized cases was late (on 8th day of fever), with stridor due to laryngeal diphtheria. The third child presented with bull neck, and developed myocarditis. These three cases proved fatal. Six cases which presented early and were managed in time recovered fully. Conclusion Unimmunized children as well as adults are susceptible to diphtheria. High immunization coverage is the only tool to control this infection. Booster doses are needed to control disease in adults. It was found that early diagnosis with high index of suspicion and early administration of ADS along with good supportive therapy carried good prognosis. Every otolaryngologist, pediatrician as well as general practitioner should be ready to manage the cases of diphtheria. Government should be prepared to manage and control epidemics effectively. How to cite this article Murthy GSN, Bhimeswar R, Kumar MV, Prasad PK. Resurgence of Diphtheria: Are We ready to treat? Int J Phonosurg Laryngol 2013;3(2):42-45.

Ludwigs Angina: lessons learned

<h3>Introduction</h3> Ludwigs Angina is a rapidly progressive gangrenous cellulitis of the submandibular space historically associated with a high mortality rate due to airway obstruction. In 90% of adults the aetiology is odontogenic whilst in children an odontogenic source accounts for a third of cases. The microorganisms implicated include a range of bacteria, particularly streptococcal species, gram-negative rods and anaerobes. <h3>Objective</h3> This clinical case presentation aims to highlight the lessons learnt in the management of a young child with Ludwig9s Angina. <h3>Population and Methods</h3> A previously well 13-month-old girl presented with pyrexia and acute swelling of the neck and floor of mouth following a coryzal illness. Intravenous antibiotic therapy was commenced at her local hospital. Despite this she deteriorated rapidly with increasing respiratory compromise requiring intubation and transfer to the regional PICU. We describe her further conservative yet aggressive management with steroids, antibiotics and conservative ENT care in a tertiary care setting. <h3>Results</h3> Neck ultrasound showed extensive subcutaneous oedema with no focal abscess. A clinical diagnosis of Ludwig9s Angina was made after specialist paediatric ENT assessment. The neck swelling and upper airway oedema improved but her clinical course was complicated by lower respiratory tract infection. Tracheal secretions were positive for parainfluenzae type 3. Haemophilus influenzae and Moraxella catarrhalis were isolated from bronchoalveolar lavage fluid. In total she required PICU care for 7 days and ventilatory support for 5 days. <h3>Conclusions</h3> Valuable lessons can be learned from this clinical case: (1)Ludwigs Angina has a typical bull neck appearance with diffuse brawny swelling of the neck. (2)It is a cause of acute rapidly progressive airway obstruction and may present as a life threatening airway emergency. (3)It may be complicated by contiguous spread of infection within the respiratory tract. (4)Viral upper respiratory tract infection followed by Gram negative bacterial infection is a recognised infectious aetiology with the viral infection facilitating polymicrobial infection. Microbiological diagnosis is helpful to guide prognosis as well as management. (5)Early recognition of this soft tissue cellulitis is essential for prompt airway and antibiotic management.

Cardiac involvement in diphtheria: Study from a tertiary referral infectious disease hospital

Background: Diphtheria is still a fatal disease even in the era of universal immunization. Diphtheria myocarditis, one of the serious complications of respiratory diphtheria may cause death if not recognized and treated properly. Aims and Objectives: To determine the outcomes of cardiac involvement in respiratory diphtheria. Materials and Methods: One hundred (n = 100) patients with respiratory tract diphtheria were evaluated in respect to cardiac involvement. All patients were closely monitored for a minimum period of 4-6 weeks from the onset of respiratory symptoms. Continuous ECG monitoring including blood biochemistry (SGOT, CPK-MB, and Troponin-T) were done in each case. Results : The most common symptoms were throat pain seen in 94 cases, palpitation in 56 cases, bull neck in 40 cases, shortness of breath in 12 cases, fever in 9 cases, and nasal regurgitation in 8 cases. Most common complication observed was myocarditis seen in 70 patients and majority of patients (60) were asymptomatic. The ECG changes were T wave inversion in 54 patients, inappropriate sinus tachycardia in 38 patients, ST segment depression in precordial leads in 8 patients, Mobitz type II block in 6 patients, Mobitz type I block in 4 patients, RBBB in 4 patients, multiple atrial ectopics in 4 patients, and sinus bradycardia in 2 patients. A total number of five patients died. Conclusions: Myocarditis was commonest and serious complication of respiratory diphtheria. Increase in vaccination coverage and improvement of socioeconomic status are all effective preventive measures to reduce the incidence of diphtheria.